Noninvasive methods of penile lengthening: fact or fiction?

NON-INVASIVE PENILE LENGTHENING METHODSODERDA and GONTERO
Non-invasive methods of penile lengthening:
BJUI fact or fiction?B J U I N T E R N A T I O N A LMarco Oderda and Paolo GonteroUniversity of Turin, Molinette Hospital, Turin, ItalyAccepted for publication 7 May 2010
Penile size is a matter of great interest
What's known on the subject? and What does the study add?
among men who are affected by ‘short penis syndrome’ or just believe themselves
Penile lengthening methods remain a controversial issue. Surgical procedures of
“lengthening phalloplasty” are characterized by poorly defined indications and an
unacceptably high rate of complications, as recently outlined by a literature review, while
non-surgical techniques are largely popularized by the media but often lack scientific
evidence. In the literature we found only ten articles/abstracts of studies pertaining to the
With our review, we aimed to explore whether non-surgical methods of penile
lengthening may have some scientific background. We focused specifically on penile
extenders, which among conservative methods are those whose efficacy is supported by
as vacuum devices, penile traction devices
some scientific evidence. It seems that penile traction devices should be proposed as the
first-line treatment option for patients seeking a penile lengthening procedure.
exercises’ have been popularized through the media. Most of these techniques, however, are not supported by any scientific evidence.
KEYWORDS
We briefly analyse the efficacy and scientific
surgery, making these traction devices an
penile lengthening, micropenis, small penis,
of penile lengthening. It seems that penile
ideal first-line treatment option for patients
extenders represent the only evidence-based
seeking a penile lengthening procedure.INTRODUCTION
lengthening. The PubMed, Ovid, Embase and
[3]) with none being a review article. Ten dealt
Cochrane-Central Register of Controlled Trials
with general concepts related to short penis,
Penile size continues to represent a matter of
of which four were used to define the terms
great concern among men and an increasing
combinations of the following free text: ‘short
number of patients seek urological advice for
penis’, ‘penile lengthening’, ‘Peyronie’,
addressed the role of surgery for penile
the so-called ‘short penis’, wondering if there
‘extenders’, ‘micropenis’, ‘therapy’,
is the possibility of having their penis
‘dysmorphophobia’. Identified articles were
comprehensive review [2] which was kept for
enlarged. Notably, penile length is normal in
examined by the authors (M.O. and P.G.), and
comparison with the results of conservative
most of these men who tend to overestimate
the most relevant articles were selected
normal phallic dimensions [1]. Furthermore,
according to their levels of evidence, as
defined by the Oxford Centre for Evidence-
phalloplasty’ remain a controversial issue,
based Medicine [3]. In addition, abstracts
NORMAL PENILE SIZE AND CONDITIONS
presented at the 2008–2009 annual meetings
OF SHORT PENIS
indications and an unacceptably high rate of
What is a normal penile size is a knotty
literature review [2]. In this brief overview we
question which some studies have tried to
aim to explore whether non-surgical methods
answer. Penile length has to be measured
of penile lengthening, largely popularized
along the dorsal side of the penis, from the
through the media, may have some scientific
pubo-penile skin junction to the meatus,
Among the 154 reports matching our search
while the circumference is measured at the
terms, only 10 articles/abstracts of studies
mid-shaft. According to Wessells et al. [4],
MATERIALS AND METHODS
were found to pertain to the topic of the
review. These clinical data were limited to case
considered to be any length within 2 SDs
series (level of evidence 4 according to the
of the mean, that is >4 cm for the flaccid
focused on non-invasive methods of penile
Oxford Centre for Evidence-based Medicine
state and >7.5 cm for the stretched state.
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Ponchietti et al. [5] confirmed these findings,
penile skin from chronic inflammation or an
outcome [6]. In conclusion, penile extenders
concluding that >4 and >7 cm, respectively
for the flaccid and stretched states, represent
patients who complain of ‘short penis’.
the normal range, bearing in mind that these
measurements have to be interpreted in the
NON-INVASIVE METHODS OF PENILE
recommended in all patients regardless of the
light of other variables, such as body mass
LENGTHENING: A NEW PERSPECTIVE
penile length, because of the low risk of
After promising results in the treatment of
complain of ‘short penis’ and who request
Vacuum devices are used as a treatment for
short penis, penile extenders have also been
erectile dysfunction. A recent study assessed
used in an attempt to correct the defect
overestimate ‘normal’ penile length [1]. They
associated with Peyronie’s disease. The first-
suffer from so-called ‘dysmorphophobia’, a
condition consisting of an imaginary flaw in
the physical appearance [6], in this case a
physical change after 6 months of therapy.
treatment, although there is little evidence
false perception of inadequacy of the penis
Vacuum treatment of the penis was not found
that this is effective; alternatively, the surgical
even though its dimensions fall within the
to be effective for penile elongation, although
option must be considered once the disease
normal range [7]. Dysmorphophobia can be an
has been stabilized [17]. In 2008, a non-
aesthetic issue, if the altered perception
controlled pilot study by Aberne and Levine
concerns the penis in its flaccid state, or
functional, during erection [8]. In both cases,
with intralesional verapamil injections plus
the psychological aspect should be the main
concern and a multidisciplinary approach,
Recently, great attention has been given to
injections alone. Another pilot study [19]
penile extenders, non-surgical devices that
suggested prolonged daily external penile
psychological assessment, is advised [9]. A
generate progressive mechanical traction to
traction therapy as a new approach for the
the penis. Although there are only a few well-
non-surgical treatment of Peyronie’s disease,
patients how they compared with other men
conducted studies to assess their efficacy, it
with the rationale that chronic traction can
[5]. This tool was found to be very useful
cause soft tissue cellular proliferation, and
to reassure these patients: in a study by
effective and durable lengthening of the
eventually reduce penile curvature. This study
Mondaini et al. [1], 70% of their sample felt
penis, in both the flaccid and the stretched
actually showed curvature was reduced by
reassured after being educated about the
states [7]. In 2002, a small study by Colpi et al.
10–45∞ after 6 months of use of the FastSize
normal variation in penile size and was no
[15] began to unveil the efficacy of penis-
Penile extender (FastSize LLC, CA, USA).
longer interested in undergoing a surgical
stretching physiotherapy in the ‘small penis’
Stretched flaccid penile length increased 0.5–
2.0 cm and erect girth 0.5–1.0 cm. These
Penile shortening is a phenomenon associated
+3.1 cm) after 4 months of use of a penis-
confirmed by a prospective study by Gontero
with several medical and surgical conditions,
et al. [17]. After 6 months of treatment with
such as prostate cancer treated with radical
(Andromedical, S.L., Madrid, Spain) for at least
Andropenis, penile curvature improved only
minimally, from an average of 31∞ to 27∞,
showed that, after 6 months of daily use of
reduction in penile length was recorded 3
the same extender device for ≥4 h/day, there
satisfaction was obtained: this was probably
was a significant gain in length, of 2.3 and
prostatectomy [10], although the aetiology is
1.7 cm for the flaccid and stretched penis,
(1.3 cm) and flaccid (0.83 cm) penile lengths.
not clear. A statistically significant decrease in
respectively, but no significant change in
The authors, however, explained that the
penile length was also found in men treated
penile girth was detected. These findings were
particular selection of patients (stabilized
with hormonal suppression plus radiation
disease, penile curvature <50∞, no severe
conducted by Nikoobakht et al. [16], who
penile shortening is represented by Peyronie’s
found a statistically significant increase in
underestimation of the potential efficacy of
disease, an acquired penile deformity of the
length, both for the flaccid and for the
erect penis, caused by fibrous plaque. Both the
stretched state, after 3 months of use of the
natural history of the disease and the scarring
Golden Erect extender device (Ronas Tajhiz
process after surgical repair can cause a
Teb, Tehran, Iran). This study also failed to
decrease in penile length [12]. Short penis can
show any significant change in penile girth,
Other devices include penoscrotal rings that,
also be congenital, as a result of embryonic or
although it suggested the possibility of glans
developmental defects. Lastly, sometimes the
penis enhancement. Treatment with penile
inhibitors, might help to augment penile size
shortness of the penis is the result of the so-
extenders is generally reported to be well-
and maintain erections in men suffering from
called ‘hidden penis’ [13], a condition caused
tolerated, although longer daily use would
anxiety [20]. To our knowledge, however, the
by obesity, aging with an overlying fold of
probably reduce patients’ compliance [6,16],
efficacy of these devices has been described in
abdominal fat and skin, and a shortage of
and the patients seem to be happy with the
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a high risk of patient dissatisfaction because
of additional penile shortening. The current
A recent study by Shaeer et al. [21] proposed
evidence suggests that selected cases may
injection of botulinum toxin as an alternative
No comparative studies have been conducted
benefit from a conservative approach with
to surgery and penile extenders for alleviating
so far between surgical and conservative
penile retraction in patients suffering from
methods of penile lengthening. Reviewing the
recent literature, however, it would seem that
In conclusion, level 4 evidence (according to
retraction reflex. This preliminary report
extenders represent an effective and durable
Medicine) suggests that penile extenders are
potential effect in temporarily decreasing
method of penile lengthening, capable of
penile retractions, as well as improving flaccid
elongating the penis by an average of 1.5–
penile lengthening, although further studies,
2.5 cm, with minimal side effects. We should
preferably comparative, should be performed
keep in mind, though, that published data on
penile extenders are still limited to non-
controlled case series. Further comparative
CONFLICT OF INTEREST
studies should be performed to gain more
evidence. Table 1 [7,8,14–17,19,23–26] shows
advertisements for non-invasive procedures
the results of the main studies conducted on
that should increase penile size, taking
the techniques of penile lengthening.REFERENCES
small penises. This is the case for ‘penile lengthening exercises’, a technique that in
CONCLUSIONS
1 Mondaini N, Ponchietti R, Gontero P
spite of the lack of any scientific evidence
et al. Penile length is normal in most men
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by up to 3 inches (7.5 cm). Although this
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2 Vardi Y, Harshai Y, Gil T, Gruenwald I. A
technique is not supported by any evidence, it
their ‘under-estimated’ penis [1]. Surgery,
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surgical techniques used [2]. All those things
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considered, a non-surgical approach should
3 Phillips B, Ball C, Sackett D et al. Levels
be attempted for those patients who persist in
of evidence. Oxford Centre for Evidence-
requesting treatment. Cognitive behavioural
based Medicine Web site. Available at:
therapy can be useful in building confidence
for those suffering from dysmorphophobia
[6]. As for non-invasive physical treatments,
various procedures have been attempted –
4 Wessells H, Lue TF, McAninch JW.
vacuum devices, penile extenders, penoscrotal
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claimed that penile extenders can increase
penile traction devices are the technique for
penile circumference by 0.6–1 cm/month [22].
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It is not clear why these devices should be
scientific evidence. This is mainly generated
Loro F, Biscioni S, Masieri L. Penile
effective in enhancing penile girth; it has been
hypothesized that chronic traction causes
comparative design and further studies are
3300 young Italian men. Eur Urol 2001;
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needed. While the penis can effectively be
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growth in a multiplanar fashion [19]. These
elongated by an average of 1.5–2.5 cm based
6 Wylie KR, Eardley I. Penile size and the
findings, however, were not confirmed by a
on the underlying condition, there is no
‘small penis syndrome’. Br J Urol 2007; 99:
study by Gontero et al. [7], who found only
evidence that the girth can be increased by
negligible changes in penile girth after 6
applying traction forces. Taking into account
7 Gontero P, Di Marco M, Giubilei G et al.
months of traction therapy. Nikoobakht et al.
that surgical methods are not supported by a
A pilot phase-II prospective study to test
[16] did not find significant changes in
better scientific background nor have they
the ‘efficacy’ and tolerability of a penile-
shown better results, penile traction devices
extender device in the treatment of ‘short
although a significant difference was found in
should be proposed as a first-line treatment
penis’. Br J Urol 2008; 103: 793–7
glans penile circumference. It is interesting,
8 Spyropoulos E, Christoforidis C,
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Selecting CFD Software A. Selecting CFD Software A.1 Preamble This appendix outlines the procedure that was undertaken in selecting a suitable A.2 Specification of the CFD Package A list of desired features was compiled after consulting various publications (e.g. Jones and Whittle (1992), Fawcett (1991), and Shaw (1992)) and holding conversations with experienced CFD users. The f